Attention: All Providers

Public Notice

The Department of Health and Human Services, Division of Medical Assistance hereby provides notice of its intent to amend the Medicaid State Plan for the purpose of revising rate methodology language to reflect an inflationary adjustment factor of zero (0) percent for SFY 2009 – 2010 to all Medicaid private and public providers with the following exceptions: federally qualified health clinics, rural health centers, State institutions, outpatient hospitals, pharmacies and the noninflationary components of the case-mix reimbursement system for nursing facilities. Medicaid rates predicated upon Medicare fee schedules shall follow Medicare reductions but not Medicare increases unless federally required. Inflationary increases for Medicaid providers paying provider fees (private ICF-MRs and nursing facilities) can occur if the State share of the increases can be funded with provider fees.

A public notice will be issued for any future rates adjustments for SFY 2009 – 2010.

This amendment will become effective July 1, 2009.

The annual estimated state fiscal impact of this change is:

SFY 2009-2010 ($ 63,000,443).

SFY 2010-2011 ($ 63,000,443).

A copy of the proposed amendment(s) may be viewed at the county department of social services. Questions, comments and requests for copies of the proposed State Plan amendment should be directed to the Division of Medical Assistance at the address listed below.

Attention: All Providers

National Provider Identifier Guidelines for Claims Filed With a CCNC/CA Referral

Effective with date of processing May 1, 2009, the 7-digit Carolina ACCESS Medicaid Provider Referral Number is no longer accepted on paper or electronic claims. In order to receive payment and avoid denials, submit ONLY the Carolina ACCESS National Provider Identifier (NPI) referral number in block 17b on the CMS-1500 claim form or on the left side of form locator 78 on the UB-04 claim form.

To determine the recipient’s primary care provider (PCP) and whether to obtain the group NPI or individual NPI for the Carolina ACCESS referral authorization, refer to the recipient’s Medicaid identification (MID) card or the Automated Voice Response (AVR) system. When calling the AVR system for PCP information, select option 6 for eligibility, and then option 2 for enrollment.

Tips on Submitting Claims for Carolina ACCESS Recipients

A taxonomy code for the referring provider is NEVER required.

NPI is NOT used for Carolina ACCESS overrides. Providers must continue to submit the override number in block 17a on the CMS-1500 claim form or on the right side of form locator 78 on the UB-04 claim form along with the appropriate qualifier when applicable: 1D on the CMS-1500 claim form and G2 on the UB-04 claim form.

Note: Qualifiers are required onlywhen billing paper claims. They are not required when using the NCECSWeb Tool. Providers using a software vendor or clearinghouse, should contact them to verify whether qualifiers are required.

Block 17 (name) is NOT a required field on the CMS-1500 claim form.

After obtaining the Carolina ACCESS NPI from the PCP, verify that the NPI matches the provider name on the recipient’s MID card and/or on the AVR system by using the NPI and Address Database on DMA’s website.

Note: Coordination of care is a required component of CCNC/CA. PCPs are responsible for ensuring that they have provided their correct Carolina ACCESS NPI to the referring provider.
NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

Submitting ZIP+4 on Claims

The N.C. Medicaid National Provider Identifier (NPI) mapping solution uses both billing (accounting) and service facility ZIP codes to map claims. Providers with one NPI that represents multiple Medicaid provider numbers at different locations must submit the ZIP+4 that is on file for the appropriate provider number, in order for claims to map properly.

Also, within the ZIP code mapping step, the accounting ZIP+4 is considered first. If no match is found, it moves to service facility ZIP+4. Providers may need to add an accounting address to additional provider numbers for mapping purposes.

Always include your service facility ZIP+4 when completing your claim. On the NCECSWeb Tool there is a specific field for the service facility ZIP code. On the CMS-1500, the service facility ZIP+4 is entered in block 32. On the UB-04, the service facility ZIP+4 is entered in form locator 1 as the “attending physician” ZIP.

NPI – Get it! Share It! Use It! Getting one is free – Not having one can be costly!

Attention: All Providers

Updated EOB Code Crosswalk to HIPAA Standard Codes

The list of standard national codes used on the Electronic Remittance Advice (ERA) has been cross-walked to EOB codes as an informational aid to adjudicated claims listed on the Remittance and Status Report (RA). An updated version of the list is available on DMA’s HIPAA web page.

With the implementation of standards for electronic transactions mandated by HIPAA, providers now have the option to receive an ERA in addition to the paper version of the RA.

The EOB codes that providers currently receive on a paper RA are not used on the ERA. Because the EOB codes on the paper RA provide a greater level of detail on claim denials, all providers will continue to receive the paper version of the RA, even if they choose to receive the ERA transaction. The crosswalk is current as of the date of publication. Providers will be notified of changes to the crosswalk through future Medicaid bulletins.

Attention: All Providers

Electronic Claims Submission

As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program will require all providers to file claims electronically. Providers will be notified of the implementation date for this requirement in a future Medicaid bulletin.

By submitting claims electronically, providers have the advantage of expedited claims processing and improved cash flow. Electronic claims software includes time-saving features such as automatic insertion of required claims information, retrieval of previously submitted claims from backup files, and generation of lists of commonly used billing codes. Claims submitted electronically by 5:00 p.m. on the cut-off date are processed in the following checkwrite.

Electronic Claims Submission AgreementProviders who did not complete an Electronic Claims Submission (ECS) Agreement at the time of their enrollment must now complete and submit an ECS Agreement. Effective with this requirement, all providers enrolling in the N.C. Medicaid Program will be required to complete and submit the ECS Agreement in their Provider Enrollment Packet. Providers who are already filing claims electronically do not need to resubmit an ECS Agreement.

The ECS Agreement must be submitted and approved prior to submitting claims electronically, regardless of how claims are submitted – through a clearinghouse, with software obtained from an approved vendor, or through the NCECSWeb Tool. Once notification of approval is received, providers must contact the EDS Electronic Commerce Services Unit (1-800-688-6696 or 919-851-8888, option 1) to obtain a logon ID and password for electronic claims submission.

Group providers must submit the name and Medicaid Provider Number for each individual provider affiliated with their group for whom they will be submitting claims using their group provider number. This is required even if there is only one provider in the group. The Electronic Claims Submission Agreement for the group must be signed by each individual provider, which authorizes the group to use the individual's National Provider Identifier to bill Medicaid for services provided.

Trading Partner AgreementProviders and clearinghouses that bill HIPAA-compliant transactions directly to N.C. Medicaid are required to complete and submit a Trading Partner Agreement (TPA) to N.C. Medicaid. The TPA stipulates the general terms and conditions by which the partners agree to exchange information electronically. The form is available on DMA's Provider Forms web page.

Additional information regarding billing claims electronically is available in the Basic Medicaid Billing Guide on DMA's website or by calling the EDS Electronic Commerce Services Unit at 1-800-688-6696 or 919-851-8888, option 1.

Electronic Claim ExceptionsThe following list outlines some of the situations in which a claim must be billed on paper.

Medicare HMO (Part C) primary claims

Medicare Part A inpatient claims submitted directly to Medicaid

Services that require an invoice to be submitted with the claim including, but not limited to

Hearing aids and related items

Some visual aids

Unclassified and unlisted procedures

Undelivered dentures

Compounded injectable drugs billed with an unclassified HCPCS procedure code (for example, J3490)Note: 17-P compounds do not require invoices and should be billed electronically when this provision becomes effective.

Claims submitted with a Medicaid Resolution Inquiry Form for

Time limit override

Medicare override

Third-party override

Pharmacy claims for

Charges over $9,999

Compound drugs, when the compound comprises both legend and non-legend drugs

Compound drugs, when the compound contains an over-the-counter drug

Non-covered over-the-counter drugs prior approved through EPSDT

Retroactive charges that exceed the time limit for filing

DMA-approved quantity overrides

Medicare deductibles

Synagis that does not meet the established guidelines for coverage

Depo-Provera that does not meet the established guidelines for coverage

Visual field exams requiring medical justification

Any claim that requires manual review of records after the initial filing in order to make a coverage determination

Non-covered services provided under EPSDT

Any claim billed with one of the following ICD-9-CM diagnosis codes:

584.8

589

593.9

640 through 640.9

Any professional claim billed with one of the following CPT procedure codes:

59136

59151

59120

59100

99082

Any dental claim billed with one of the following ADA procedure codes:

D0340

D0470

D7830

Any institutional claim billed with one of the following ICD-9-CM procedure codes:

66.6 through 66.9

62.41 through 62.42

63.81 through 63.85

63.89

65.51 through 65.52

65.61 through 65.62

66.71 through 66.79

66.91

66.94 through 66.99

Claims submitted with a Provider Enrollment Packet from an out-of-state provider for reimbursement of services rendered to N.C. Medicaid recipients in response to an emergency

Nursing home crossovers submitted directly to Medicaid

Only claims that comply with the exceptions listed above may be submitted on paper. All other claims are required to be submitted electronically. This list will be maintained on the DMA's Electronic Claims Exceptions web page. Providers will be notified of updates to the list through the Medicaid Bulletin.

Attention: All Providers

Electronic Funds Transfers

As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program will require all providers to receive payments electronically. Providers will be notified of the implementation date for this requirement in a future Medicaid Bulletin.

By receiving payments electronically, providers eliminate the possibility of their paper checks’ being lost, stolen, misrouted, damaged or returned to sender. Electronic funds transfers (EFT) also eliminate delays incurred in receipt of Medicaid payment for the mailing and delivery of the check, which can take 5 to 7 business days. EFT payments are deposited through a secure transaction into the provider-designated checking or savings bank account. EFT provides payment in a timely and safe manner and supports an increased cash flow to the provider’s business operation.

To initiate the automatic deposit process, providers must complete and return the Electronic Funds Transfer Authorization Agreement for Automatic Deposit form. A separate EFT form must be submitted for each provider number. Providers must submit a new EFT form if they change banks or bank accounts. A copy of the form can be obtained on DMA's Provider Forms web page. Instructions on completing the form as well as documentation requirements can be found on the EFT form. Documentation includes attaching a voided check to confirm the provider’s account number and bank transit number.

Completed forms can be returned by fax to the EDS financial unit at 919-816-3186 or by e-mail to NCXIXEFT@eds.com. Providers will continue to receive paper checks until automatic deposits begin or resume to a new bank account. When the EFT process for automatic deposits has been completed, the top left corner of the last page of the Remittance and Status Report will show “EFT number” rather than “check number.”

Attention: All Providers

Notice of Possible Medicaid Identification Card Changes

As a cost-saving measure and to increase efficiency, the N.C. Medicaid Program may begin issuance of no more than one Medicaid identification (MID) card per year to each recipient. The proposed annual cards would be printed on white stock; DMA would no longer have blue, pink, green, and buff colored MID cards. The cards would include, at a minimum, the recipient’s name, MID number, and managed care primary care provider information (if applicable).

If implemented, this change would mean that the MID card will no longer serve as proof of recipient eligibility. Providers must verify the cardholder’s current eligibility at each visit. Once providers have verified eligibility during a particular month, the provider may assume that the cardholder remains eligible for the remainder of that month.

An exception to the one card per year rule would be made for those managed care recipients who change their primary care physician or change their name. A recipient would also be able to ask the county department of social services to submit a request for a replacement card, if needed.

Should the proposed legislation be implemented, providers will be notified of the change in future Medicaid Bulletins and through Remittance and Status Report banner messages, e-mail blasts, and the DMA Budget Initiative web page.

These policies supersede previously published policies and procedures. Providers may contact EDS at
1-800-688-6696 or 919-851-8888 with billing questions.

Clinical Policy and Programs DMA, 919-855-4260

Attention: All Providers

False Claims Act Education Compliance for Federal Fiscal Year 2008

Effective January 1, 2007, Section 6023 of the Deficit Reduction Act (DRA) of 2005 requires providers receiving annual Medicaid payments of $5 million or more to educate employees, contractors, and agents about federal and state fraud and false claims laws and the whistleblower protections available under those laws.

Each year DMA will notify those providers who received a minimum of $5 million in Medicaid payments during the last federal fiscal year (October 1 through September 30) that they must submit a Letter of Attestation to Medicaid in compliance with the DRA. (A complete list of providers who meet this requirement will be available on DMA’s False Claims Act Database web page.) This minimum amount may have been paid to one
N.C. Medicaid provider number or to multiple Medicaid provider numbers associated with the same tax identification number. A separate notification will be mailed for each Medicaid provider number.

Providers must complete and submit a copy of the Letter of Attestation Form within 30 days of the date of notification. Upon completion, submit the Letter to EDS by fax or by mail.

Compliance with Section 6023 of the DRA is a condition of receiving Medicaid payments. Medicaid payments will be denied for providers who do not submit a signed Letter of Attestation within 30 days of the date of notification. Providers may resubmit claims once the signed Letter is submitted to and received by EDS.

Attention: All Providers

DMA Budget Initiative Web Page

DMA will implement a number of changes in response to proposed legislated budget reductions. Providers will be notified of operational changes and coverage, and policy changes via the Medicaid Bulletin. These changes will also be listed on DMA’s Budget Initiatives web page.

Provider ServicesDMA, 919-855-4050

Attention: All Providers

Clarification for Completing the W-9

The Medicaid provider enrollment process includes the completion of the Internal Revenue Service’s (IRS) W-9 form. The N.C. Medicaid Program must collect this information in order to correctly report income paid to the provider. The W-9 form is retained by the N.C. Medicaid Program and is not sent to the IRS. The instructions that the IRS provides with the W-9 form explain that payments you receive may be subject to backup withholding if you do not report your correct tax identification number (TIN). The instructions further explain that the TIN provided must match the name given on Line 1. Failure to provide your correct TIN may result in a penalty. (The W-9 form and instructions for completing the form are available on the Internal Revenue Service website.)

Some individual providers who are also associated with a group practice submitted their W-9 with the group’s TIN listed instead of their social security number (SSN). Now that the N.C. Medicaid Program is aware of this issue, the IRS instructions and guidelines for completion of the W-9 form will be followed. Providers who have supplied incorrect TINs in the past may correct their W-9s at any time by sending a completed Medicaid Provider Change Form with a corrected W-9 attached to the form to the address listed below.

Earnings reported on the 1099 form are based on the provider number associated with the National Provider Identifier entered on the claim form. If incorrect earnings are reported it may be because claims are incorrectly filed without the group number, which results in income being reported to the individual (attending) provider number entered on the claim. Incorrect earnings are NOT reported based on the W-9. It is important that all providers carefully review the Financial Section of their Remittance and Status Report (RA) to verify that the claim is submitted properly and income is reported to the correct TIN.

Attention: All Providers

Billing CPT Procedure Code 72295 with Modifiers 76 or 77

Effective with date of service November 1, 2008, the unit limitation for CPT procedure code 72295 (discography, lumbar, radiological supervision and interpretation) was changed to five units per day. Modifiers 76 (repeat procedure by the same physician) or 77 (repeat procedure by another physician) should no longer be used when billing 72295. Providers who received a denial with EOB 5201 (diagnostic procedure allowed once per day unless billed with appropriate modifiers) or EOB 5202 (repeat diagnostic procedure allowed twice per day) for procedure code 72295 for dates of service on or after November 1, 2008, may resubmit the denied charges as a new claim (not as an adjustment request) for processing.

No prior review is required for the extraction, space maintainer, and endodontic codes listed above.

Orthognathic surgery will be covered to correct functionally impairing malocclusions when orthodontia was approved and initiated while the child was covered by Medicaid and the need for orthognathic surgery was documented in the orthodontic treatment plan.

The following orthognathic surgery codes that may be covered if considered medically necessary:

93542 (injection procedure during cardiac catheterizations; for selective right ventricular or right atrial angiography)

93543 (injection procedure during cardiac catheterizations; for selective left ventricular or left atrial angiography)

System changes have been completed. Providers who received a denial with EOB 24 (Procedure code, procedure/modifier combination or revenue code is missing, invalid or invalid for this bill type. Correct and rebill denied detail as a new claim.) when billing CPT procedure code 93541, 93542 or 93543 with modifier 51 for dates of service on or after January 1, 2008, may resubmit the denied charges as a new claim (not an adjustment request) for processing as long as filing has been kept timely.

EDS, 1-800-688-6696 or 919-851-8888

Attention: All Providers

The Controlled Substances Reporting System: The State’s Newest Tool to Make Prescribing Opioids and Other Controlled Substances Safer and Easier

BackgroundIn 2005, the North Carolina Legislature passed enabling legislation (Article 5E. North Carolina Controlled Substances Reporting System Act § 90-113.70-76) to establish a prescription monitoring program. The stated purpose of the Act is to “improve the State’s ability to identify controlled substance abusers or misusers and refer them for treatment, and to identify and stop diversion of prescription drugs in an efficient and cost-effective manner that will not impede the appropriate medical utilization of licit controlled substances.” This legislation was in response to the newly recognized epidemic of unintentional fatal poisonings sweeping the nation and the state, resulting primarily from the increasing misuse and abuse of prescription opioids. The new, centralized database created by the Act was named the Controlled Substances Reporting System (CSRS), as it includes information only on outpatient prescriptions for controlled substances, not on other types of medications that are prescribed and dispensed in North Carolina. In July 2007, the N.C. Department of Health and Human Services (DHHS) put the CSRS into production.

One function of the system is to give providers a tool that helps them more safely and easily decide whether to prescribe opioids and other drugs with abuse or addictive potential to specific patients. All pharmacies dispensing outpatient prescriptions are mandated (see Legal Mandate, below) to report these prescriptions to a centralized database managed by DHHS. DHHS in turn may disclose information to the following entities:

Agents of the State Bureau of Investigation’s Diversion and Environmental Crimes unit, pursuant to a bona fide investigation

State licensing boards with jurisdiction over health care professionals, pursuant to an ongoing investigation

Primary monitoring authorities in other states, pursuant to an ongoing investigation

Division of Medical Assistance for the purposes of administering the State Medicaid Plan

De-identified data for statistical and research purposes only
(Legislation is pending to add medical examiners to the list.)

In addition, DHHS shall report unusual patterns of prescribing to the Attorney General. An independent multidisciplinary advisory committee has been formed to provide ongoing guidance to DHHS on the CSRS. The committee establishes reviews and revises objective criteria as to what constitutes an unusual pattern.

Legal MandateThe North Carolina Controlled Substances Reporting System Act requires that all outpatient dispensers of controlled substances in North Carolina report data to the CSRS. These data are a subset of the standard data routinely collected by most third-party vendors who provide payment reimbursement services to pharmacies, and the specific information that must be reported on each prescription is established by law.
Currently, data must be reported to the CSRS on the 15th and 30th of every month. Pending legislation may increase the reporting frequency, thus improving the currency of the data. Due to occasional reporting errors and a few late or non-complying pharmacies, the CSRS data is not 100 percent accurate. It is probably an underestimation of the actual number of potentially addictive drugs that are legally available in North Carolina.

Epidemiologic Profile of Outpatient Controlled SubstancesAlmost half of the prescriptions in the CSRS database are for narcotic analgesics (mostly opioids). In 2008, more than 16 million outpatient prescriptions were dispensed for controlled substances. Of these, the most frequently prescribed were products with hydrocodone (4,146,484 prescriptions), benzodiazepines (3,782,112 prescriptions), oxycodone (2,029,604 prescriptions) and products to treat insomnia (1,416,840 prescriptions). The prescription rates varied greatly by county, with the highest prescription rates occurring most often (but not always) in our state’s most rural areas (see Figure 1).

Although these findings have stimulated intense interest among the state’s epidemiologists, there are no studies to date that can answer even the most basic questions, like “Is the overall state annual prescription rate of 17,787 prescriptions per 10,000 residents higher than best practices would expect?” or “Why are the controlled substances prescription rates in Watauga and Wilkes counties in the lowest and highest state quartiles, respectively, even though they are contiguous counties and both are in one of the most rural areas of the Appalachians?” The CSRS provides a tool to facilitate such research. However, only de-identified CSRS data are available for statistics, research or education.

Enrolling in the CSRSMedicaid and other medical providers who are practitioners with a current DEA registration and licensed pharmacists may easily apply for access to the CSRS by completing a short enrollment application available on the CSRS website. Print, complete, sign and notarize the form and mail it to the CSRS at the address on the form. E-mail confirmation of access is often received in less than two weeks. The CSRS link is also available on the DMA Outpatient Pharmacy web page under “Related Sites.” Because of the strict confidentiality provisions in the Act, only the registered practitioner may access the system. The law prohibits other members of the practice from using it. Additionally, it is unlawful to disclose CSRS findings with anyone (including other practitioners) except the patient. (Pending legislation could change this provision.)

Using the CSRS in Medical PracticeThe CSRS is quick to use and excels in collating information that can promote safer prescribing of opioids and other controlled substances. Running a CSRS profile should be seen as a universal precaution when prescribing any controlled substance; like the universal precautions for blood drawing, it should be done for every patient every time the prescribing of a controlled substance is likely. By running a CSRS prescription profile that documents what and how many prescriptions for controlled substances have been dispensed to a patient, Medicaid providers have an additional tool by which to decide whether to write or refill a prescription. Practitioners may choose, for example, to refer the patient for more sophisticated pain management, or refer the patient for substance abuse treatment while also considering other options for pain management.

The CSRS was not designed as a means by which to “fire” a patient because of a less-than-optimal prescription profile. Because the CSRS is new and the potential for error always exists, the system cannot be assumed to be infallible. Always discuss the findings with the patient. If the patient contests the findings or the practitioner is concerned about the validity of the profile or has other questions, the practitioner may contact John Womble or William Bronson, at the Division of Mental Health, Developmental Disabilities and Substance Abuse Services, Drug Control Unit (telephone 919-733-1765, Monday through Friday between 9:00 a.m. and 5:00 p.m.).

Attention: All Providers

CSC is ready to begin the 12-month process to verify information and credential enrolled Medicaid providers who have not been credentialed in the last 18 months. CSC will notify providers by mail when verification and credentialing activities will begin for their provider types. The notification packet will be mailed to the provider's billing/accounting address and will include a pre-printed report of information currently on file with N.C. Medicaid plus a checklist of credentialing-related documents that must be returned to CSC. (Providers may verify their billing/accounting address via the DMA Provider Services NPI and Address Database or by calling the EVC Call Center.)

The pre-printed NC MMIS Verification Form includes demographic data and NPI information currently on file with N.C. Medicaid and also contains space for providers to enter license/certification numbers, type of ownership, and contact information. Providers must complete the form, attach copies of documents required for credentialing, and return the verification packet to CSC within 30 days of the date of receipt. Failure to respond to the notification may result in termination of Medicaid participation.

The verification process will take up to three weeks from the time CSC receives the correct and complete verification packet from the provider; the return of incomplete or incorrect information will prolong the verification process. CSC will review the information and conduct credentialing activities that include criminal background checks, queries of practitioner databases, and verification of licensure, certification, and endorsement.

Attention: All Providers

Time Limit Overrides

Federal guidelines require that all Medicaid claims, except hospital inpatient and nursing facility claims, must be received by EDS within 365 days of the first date of service in order to be accepted for processing and payment. All Medicaid hospital inpatient and nursing facility claims must be received within 365 days of the last date of service on the claim. If a claim was filed within the 365-day time period, providers have 18 months from the remittance advice (RA) date to refile a claim.

If the claim is a crossover from Medicare or any other third-party commercial insurance, regardless of the date of service on the claim, the provider has 180 days from the date listed on the explanation of benefits (EOB) to file the claim to Medicaid from that insurance (whether the claim was paid or denied). The provider must include the Medicaid Resolution Inquiry Form, copy of the claim, and a copy of the Third-Party or Medicare EOB in order to request a time limit override with EDS.

Claims initially received for processing within the 365-day time limit may be resubmitted to EDS on paper or electronically. The claim information must match exactly to the original claim for the recipient Medicaid identification number (MID), provider number, from date of service, and total billed. Claims that do not have an exact match to the original claim in the system will be denied for one of the following Explanation of Benefits (EOB):

0018 Claim denied. No history to justify time limit override. Claims with proper documentation should be resubmitted to EDS Provider Services Unit.

8918 Insufficient documentation to warrant time limit override. Resubmit claim with proof of timely filing—a previous RA, time limit override letter, or other insurance payment or denial letter within the previous six months.

Requests for time limit overrides must be sent to EDS with documentation showing that the original claim was submitted within the initial 365-day time period.
Examples of acceptable documentation for time limit overrides include:

Dated correspondence from DMA or EDS about the specific claim received that is within 365 days of the date of service

An explanation of Medicare benefits or other third-party insurance benefits dated within 180 days from the date of Medicare or other third-party payment or denial.

A copy of the RA showing that the claim is pending or denied; the denial must be for reasons other than time limit.

Examples of unacceptable documentation may include, but not limited to:

The billing date on the claim or a copy of an office ledger.

The date that the claim was submitted does not verify that the claim was received by EDS within the 365-day time limit.

When submitting inquiry forms, always attach the claim and a copy of any paper RAs related to the inquiry form, as well as any other information related to the claim (provider-generated RAs or electronic RAs are not acceptable). Each inquiry request requires a separate form and copies of documentation (vouchers and attachments). Because these documents are scanned for processing, attach only single-sided documents to the inquiry request. Do not attach double sided documents to the inquiry request. A copy of the Medicaid Resolution Inquiry Form is on DMA’s Provider Forms web page.

Retro Eligibility and Retroactive Prior ApprovalIn some instances an application for Medicaid benefits is initially denied and then later approved due to a reversal of a disability denial, a state appeal, or a court decision. A time limit override may be needed in some cases; the county department of social services (DSS) is responsible for requesting this override base on date of approval. When a time limit override is warranted, the county department of social services will provide written notice to the recipient outlining the specific dates of service when the Time Limit Override is approved. Recipients are instructed to immediately notify the provider of retroactive approval. When this occurs, providers can file claims for these specific dates of service outlined in the recipient letter. The provider must file these claims within six months of determination as outlined in the recipient letter.

Retroactive prior approval is considered when a recipient, who does not have Medicaid coverage at the time of the procedure, is later approved for Medicaid with a retroactive eligibility date. Because some of these appeals and reversals are not final for many months, the county DSS can request an override of the claims filing time limit from DMA.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Nurse Practitioners and Physicians

Effective with date of service May 5, 2009, the N.C. Medicaid Program added the FDA-approved diagnosis of glioblastoma to the required list of diagnoses for bevacizumab (Avastin) when billed through the Physician’s Drug Program. Avastin is indicated as a single agent for patients whose glioblastoma progressed despite prior therapy.

Certain ICD-9-CM diagnosis codes are required when billing for Avastin.

One of the following diagnosis codes must be billed with V58.11 (encounter for chemotherapy):

153.0 through 154.8 (malignant neoplasm of the colon, rectum, recto-sigmoid junction, and anus)OR

Attention: Nurse Practitioners and Physicians

There was an error in the table published in the April 2009 Medicaid Bulletin article that provided guidance on the ICD-9-CM diagnosis codes required when billing bendamustine (Treanda, HCPCS procedure codes J9999 and J9033) for non-Hodgkin’s lymphoma. For “other malignant neoplasms of lymphoid and histiocytic tissue,” the range of codes should have been listed as 202.00 through 202.98.

Refer to the corrected table below when billing for Treanda.

Dates of Service

HCPCS Procedure Code

ICD-9-CM Diagnosis Code

ICD-9-CM Diagnosis Code Description

March 1, 2008, through September 30, 2008

J9999

V58.11

Encounter for antineoplastic chemotherapy

AND

204.10 through 204.11

Lymphoid leukemia, chronic, without mention of remission, in remission

October 1, 2008, through October 31, 2008

J9999

V58.11

Encounter for antineoplastic chemotherapy

AND

204.10 through 204.12

Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse

November 1, 2008, through December 31, 2008

J9999

V58.11

Encounter for antineoplastic chemotherapy

AND

204.10 through 204.12

Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse

OR oneof these non-Hodgkin’s lymphoma diagnosis codes:

200.00 through 200.88

Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue

202.00 through 202.98

Other malignant neoplasms of lymphoid and histiocytic tissue

January 1, 2009, and after

J9033

V58.11

Encounter for antineoplastic chemotherapy

AND

204.10 through 204.12

Lymphoid leukemia, chronic, without mention of remission, in remission or in relapse

OR oneof these non-Hodgkin’s lymphoma diagnosis codes:

200.00 through 200.88

Lymphosarcoma and reticulosarcoma and other specified malignant tumors of lymphatic tissue

202.00 through 202.98

Other malignant neoplasms of lymphoid and histiocytic tissue

EDS, 1-800-688-6696 or 919-851-8888

Attention: Nurse Practitioners and Physicians

Factor VIII (Xyntha, HCPCS Procedure Code Q2023): Billing Guidelines

Effective with date of service July 1, 2009, the N.C. Medicaid Program covers factor VIII (antihemophilic factor, recombinant) (Xyntha) per IU for use in the Physician’s Drug Program when billed with HCPCS procedure code Q2023. Xyntha is available in vials containing 250, 500, 1000, and 2000 IUs.

Xyntha is indicated for patients with hemophilia A. Xyntha, administered intravenously, may be used for the control and prevention of bleeding episodes or for surgical prophylaxis.

Attention: Pharmacists

Prescription Origin Code

As a reminder, effective August 1, 2009, the use of NCPDP field 419-DJ (prescription origin code) will become mandatory for the N.C. Medicaid Outpatient Pharmacy Program. This field indicates the origin of the prescription. The following standard values will be accepted in this field:

1 = Written

2 = Telephone

3 = Electronic

4 = Facsimile

Zero and null values will not be accepted. This requirement will apply only to new prescriptions and will not apply to refills. The information entered into the prescription origin code field is required to assist with auditing processes.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Nurse Practitioners and Physicians

Effective with date of service July 1, 2009, the N.C. Medicaid Program covers lacosamide injectable (Vimpat) for use in the Physician’s Drug Program when billed with HCPCS procedure code J3490 (unclassified drugs). Vimpat is available as 200-mg/20-ml single-use vials with a concentration of 10 mg/ml. Vimpat is indicated as adjunctive therapy in the treatment of partial-onset seizures when oral administration is temporarily not feasible.

Vimpat is initially administered intravenously with a dosage of 50 mg twice daily. The dosage may be increased at weekly intervals by 100 mg/day and is administered intravenously as two divided doses up to the recommended maintenance dosage of 200 to 400 mg/day. This recommended maintenance dosage is based on individual patient response and tolerability. When switching from oral to IV lacosamide, the initial total daily IV dosage of lacosamide should be equivalent to the total daily dosage and frequency of oral lacosamide and should be infused intravenously over a period of 30 to 60 minutes.

Attention: Nurse Practitioners and Physicians

Effective with date of service July 1, 2009, the N.C. Medicaid Program covers golimumab injectable (Simponi) for use in the Physician’s Drug Program when billed with HCPCS code J3590 (unclassified biologicals). Simponi is available as either pre-filled syringes (50 mg per 0.5 ml) or pre-filled SmartJect autoinjectors (50 mg per
0.5 ml).

Simponi is administered as a subcutaneous (SC) injection once a month. The recommended dose for Simponi is 50 mg.

Prior to initiating Simponi and periodically during therapy, patients should be evaluated for active tuberculosis and tested for latent infection. For patients with RA, Simponi should be given in combination with methotrexate; for patients with PsA or AS, Simponi may be given with or without methotrexate or other non-biologic
disease-modifying antirheumatic drugs (DMARDs). For patients with RA, PsA, or AS, corticosteroids,
non-biologic DMARDs, and/or nonsteroidal anti-inflammatory drugs (NSAIDs) may be continued during treatment with Simponi.

For Medicaid Billing

The ICD-9-CM diagnosis codes required for billing Simponi are:

714.0 through 714.9 (rheumatoid arthritis and other inflammatory polyarthropathies)OR

One Medicaid unit of coverage is 50 mg. The maximum reimbursement rate, per 50 mg, is $3,543.75.

Providers must indicate the number of HCPCS procedure code units used in block 24G on the CMS-1500 claim form or the electronic equivalent.

Providers must bill NDC codes and NDC units. The NDC units should be reported as “ML.” For example, for each 50 mg administered (0.5 ml from either the disposable pen or the disposable syringe), the NDC units should be reported as “ML0.5.” Refer to the March 2009 Special Bulletin, National Drug Code Implementation, Phase III, for instructions. Medicaid covers only rebatable NDCs.

Insulin Syringes

Effective date of service July 17, 2009, insulin syringes will be covered as an over-the-counter product in the
N.C. Medicaid Outpatient Pharmacy Program. Recipients must have a prescription for the insulin syringes and there must be an insulin prescription on file within the last 90 days in order to bill using the pharmacy point-of-sale system. Syringes are supplies that must be billed in multiples of 10 and a National Drug Code (NDC) must be used when billing through point-of-sale. Rates apply to syringes; therefore, no copayments or dispensing fees apply. Medicare Part D continues to cover insulin syringes for dual eligible recipients.

Syringes do not have to be purchased at the same pharmacy as the insulin unless the patient is locked into a pharmacy. Recipients identified for the Focused Risk Management (FORM) Program who require more than
11 unduplicated prescriptions each month are restricted to a single pharmacy. In these cases, the insulin syringes must be purchased at the same pharmacy.

Insulin syringes will no longer require authorization by a recipient’s CCNC/CA primary care provider. Lancets and strips will not be paid through point-of-sale. These items will continue to require authorization by a recipient’s CCNC/CA primary care provider.

Provision of Diapers and Non-Sterile Gloves

Medicaid coverage of incontinent supplies (i.e., diapers and Chux) is limited to recipients ages 3 years and older. Diapers for recipients under the age of 3 years are age-appropriate and, therefore, do not meet the medical necessity criteria for coverage. All Medicaid-covered medical supplies must meet medical necessity criteria, be specifically ordered by the physician, and be indicated on the recipient’s plan of care. Medical necessity criteria include the item being age-appropriate.

Non-sterile gloves for use by agency staff in providing services to the recipient are considered an administrative cost to the agency and are included in the Medicaid reimbursement rate for the service. The gloves cannot be billed to Medicaid as a separate charge. Non-sterile gloves are covered for family members and similar caregivers only if the caregiver is in contact with the patient’s blood or other potentially infectious body fluids. The gloves must be specifically ordered by the physician in the plan of care. The medical record must contain documentation regarding the condition or illness that requires the medical supplies and reflect usage to support the quantity being delivered.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Anesthesia Providers

Anesthesia Modifier AD

Effective with date of service December 1, 2007, DMA implemented the use of anesthesia modifier AD (medical supervision by a physician of more than four concurrent anesthesia procedures). System changes are now complete. The following guidelines must be used when billing the AD modifier.

Anesthesiologists who provide supervision to more than four anesthesia procedures performed by Certified Registered Nurse Anesthetists (CRNAs) will bill for the procedure using only the AD modifier. The QZ modifier (CRNA service: without medical direction by a physician) must be appended to the anesthesia CPT procedure code on the CRNA’s claim. The anesthesiologist will be reimbursed 45 base units for every procedure being supervised, and may bill a one-time 15-minute block of time if the anesthesiologist can document presence at anesthetic induction in the medical record.

The anesthesiologist’s claim form will list the procedure code plus modifier AD and 0 (zero) units. The provider will be reimbursed for 45 base units. If present during anesthetic induction: list procedure code plus modifier AD and 15 units. Reimbursement will be for 60 base units. Only one claim detail for each procedure, with either 0 or 15 units appended, will be accepted. All other combinations of AD modifier and number of units will be denied. Medical record documentation must support claims billed. Normal timely filing guidelines apply.

The supervised CRNA’s claim form will list the procedure code and modifier QZ plus the time.

Direct-enrolled mental health practitioners who provide services to a CCNC/CA enrollee under the age of
21 years must have a referral from the CCNC/CA primary care provider, a Medicaid-enrolled psychiatrist or the Local Management Entity (LME). When the service is provided without an appropriate referral, an override cannot be given by CCNC/CA.

It is the responsibility of the provider to make sure they have a referral before services are rendered. If treatment is provided without a referral from one of the three entities listed above, the service provider’s claim will be denied with EOB 2270 (Service must be referred by Carolina ACCESS PCP, LME, or Medicaid-enrolled psychiatrist. Enter referral number on claim or contact EDS Provider Services if referral number is correct.).

Managed CareDMA, 919-855-4780

Attention: Hospital Outpatient Clinics

Immune Globulins Billed with HCPCS Level I Procedure Codes

Effective with date of processing July 1, 2009, the N.C. Medicaid Program requires that immune globulins billed on institutional claims using Revenue Codes 250 or 636 plus CPT procedure codes 90281 through 90399 be reported with National Drug Codes (NDCs). Only rebatable NDCs are covered.

Providers must identify 340B drugs dispensed in an outpatient or clinic setting by using the UD modifier. This will allow Medicaid to identify claim details for 340B drugs and exclude them from the rebate collection process. All non-340B drugs are billed using the applicable HCPCS procedure code and NDC pair without the UD modifier.

Refer to the article titled UD Modifier and 340B Drugs in the June 2009 Medicaid Bulletin for additional information on billing for 340B drugs.

Mental Health Cost Report Training Sessions

Training is being offered for those providers who have a fiscal year end of March 31, 2009, or June 30, 2009. The training scheduled at several locations across the state during the month of July. Those providers with a fiscal year end of September 30, 2009, or December 31, 2009, should wait to go to training when sessions are offered this winter.

To learn more about training, locations, times, and information on how to register for training, visit the Office of the Controller’s website and click on the link to the Mental Health Cost Report Training Memo. The memo also provides the link to the website where you can register.

For questions concerning this training or the Mental Health Cost Report, contact Bill Caddell at Bill.Caddell@dhhs.nc.gov or 919-855-3681.

The deadline for coverage of provisionally licensed providers delivering outpatient behavioral health services as a reimbursable service under Medicaid and state funds and billed through the Local Management Entity (LME) has been extended to June 30, 2010. DMA and DMH will continue to pay for services delivered by the provisionally licensed individuals listed above when billed through LMEs under HCPCS procedure codes H0001, H0004, and H0005 until that date.

As outlined in Implementation Update # 32 (on the DMH
Enhanced Services Implementation Updates web page), the LME may choose to provide this billing service on behalf of the provisionally licensed professional. If the provisionally licensed professional is employed by an agency, the agency must develop a contract directly with the LME to do this billing for them. If provisionally licensed professionals work independently, they should contact their licensure board prior to developing a contract with the LME to ensure compliance with each profession’s scope of practice.

In addition to providing outpatient behavioral health services billed through an LME, there are various other means for provisionally licensed professionals to obtain the clinical experience required by their licensing boards. These include

This is a reminder of current outpatient prior authorization and billing guidelines for outpatient behavioral health services outlined in the June 2009 Implementation Update/Medicaid Bulletin. ValueOptions has revised the current Outpatient Review Form (ORF2). Please see the ValueOptions website for the revised form.

Effective July 1, 2009, providers must use the revised ORF2 for prior authorization requests. Providers should pay special attention to these two fields on the revised form:

Attending Provider Name/Medicaid #

Billing Provider Name/Medicaid #

Both fields must be completed. Prior authorizations will be created for the Billing Provider/Medicaid provider number. Providers must enter the Billing Medicaid provider number associated with the Billing NPI with which they will submit their claims (do not submit NPI on the ORF2).

Prior authorization requests for group providers will cover all providers under that Billing Medicaid provider number. Do not submit a new request for a provider who fills in should the primary provider be absent.

After September 1, 2009, ValueOptions will return any request as “Unable to Process” if it is submitted on the old ORF2 form or if the two fields noted above are not completed.

This is a clarification of the prior approval guidelines outlined in the March 2009 and May 2009 Medicaid Bulletins. In order to facilitate best practice and integrated care for clients, CPT procedure codes 99408 and 99409 do not require prior authorization. These codes are also used by physicians and other medical professionals for substance abuse assessments and screenings. ValueOptions will not process prior authorization requests submitted for these CPT procedure codes.

Attention: Outpatient Behavioral Health Providers Who Are Employed in a Physician’s Office or Clinic, a Hospital Outpatient Department, or a Local Health Department or School Based Health Center

DMA has extended the sunset clause for nurse practitioners who provide outpatient behavioral health services. DMA will allow nurse practitioners who possess an Advanced Certification in areas other than psychiatric nursing, and who have two years of mental health experience to enroll under this sunset clause. Under this clause, all nurse practitioners will be required to complete and submit the Advanced Psychiatric Certification to DMA Provider Services on or before June 30, 2015. Failure to complete the certification by June 30, 2015, will result in termination of participation in the N.C. Medicaid Program. It is DMA’s expectation that all providers will practice within the scope of their licensure, training, and practice competencies.

Enhanced Behavioral Health Services Seminars

The Enhanced Behavioral Health Services Provider Seminars scheduled for August 2009 have been cancelled.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Hospitals

Grouper 25 Implementation

In April 2009, following approval from CNS, DMA implemented Grouper 25/MCE version 24 software for inpatient claim processing. As a result of the retroactive implemenation of the grouper software, a recoup/repay of all hospital inpatient claims with discharge date of service after October 1, 2008, was necessary. These recoup/repays were processed based on the hospital fiscal year end (HFYE) date according to the table below.

Group

Hospital Fiscal Year End Date

Remittance and Status Report (RA) Dates

Group 1

12/31/2008

5/28/2009 and 6/9/2009

Group 2

4/30/2009 and 5/31/2009

6/16/2009 and 6/25/2009

Group 3

6/30/2009 and 7/31/2009

6/16/2009 and 6/25/2009

Group 4

8/31/2009 and 9/30/2009

6/25/2009 and 7/7/2009

Hospitals began to see these recoup/repays on their remittance status advices starting June 6, 2009.

EDS, 1-800-688-6696 or 919-851-8888

Attention: Institutional (UB-04/837I) Billers

ICD-9-CM Procedure Codes Requirements Update

To comply with regulations mandated by HIPAA, in the February 2009 Medicaid Bulletin article titled ICD-9-CM Procedure Codes, DMA announced its intention to limit the use of ICD-9-CM procedure codes to the reporting of inpatient procedures by hospitals and to deny all other claims submitted with ICD-9-CM procedure codes including outpatient, nursing home, adult care homes, home health, hospice, and residential child care treatment facility services.

Implementation of these changes has been delayed until further notice.

EDS, 1-800-688-6696 or 919-851-8888

Early and Periodic Screening, Diagnosis and Treatment and Applicability to Medicaid Services and Providers

Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria stated in this publication may be exceeded or may not apply to recipients under 21 years of age if the provider's documentation shows that

the requested service is medically necessary to correct or ameliorate a defect, physical or mental illness, or health problem; and

all other Early and Periodic Screening, Diagnosis and Treatment (EPSDT) criteria are met.

This applies to both proposed and current limitations. Providers should review any information in this publication that contains limitations in the context of EPSDT and apply that information to their service requests for recipients under 21 years of age. A brief summary of EPSDT follows.

EPSDT is a federal Medicaid requirement (42 U.S.C. § 1396d(r) of the Social Security Act) that requires the coverage of services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination (including any evaluation by a physician or other licensed clinician).

This means that EPSDT covers most of the medical or remedial care a child needs to

improve or maintain his or her health in the best condition possible OR

compensate for a health problem OR

prevent it from worsening OR

prevent the development of additional health problems

Medically necessary services will be provided in the most economic mode possible, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers.

EPSDT does not require the state Medicaid agency to provide any service, product, or procedure that is unsafe, ineffective, experimental, or investigational; that is not medical in nature; or that is not generally recognized as an accepted method of medical practice or treatment.

If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does not eliminate the requirement for prior approval.

For important additional information about EPSDT, please visit the following websites:

Proposed Clinical Coverage Policies

In accordance with NCGS §108A-54.2, proposed new or amended Medicaid clinical coverage policies are available for review and comment on DMA's website. To submit a comment related to a policy, refer to the instructions on the Proposed Clinical Coverage Policies web page. Providers without Internet access can submit written comments to the address listed below.

Electronic claims must be transmitted and completed by 5:00 p.m. on the cut-off date to be included in the next checkwrite. Any claims transmitted after 5:00 p.m. will be processed on the second checkwrite following the transmission date.